Colorectal cancer (CRC) is one of the most commonly diagnosed cancers in the U.S. and is a leading cause of cancer death. African Americans (AAs) have significantly higher CRC mortality rates than European Americans (EAs). Post-treatment (defined as post-surgical) surveillance is critical to screen for cancer recurrence and promote lifestyle changes to reduce risk of recurrence. However, most survivors do not receive guideline-recommended surveillance. Little is known about factors associated with adherence to clinical surveillance guidelines (i.e., office visits, carcionoembryonic antigen (CEA) tests, colonoscopy) or adherence to lifestyle-related surveillance guidelines for weight, exercise, alcohol and tobacco use. The purpose of this R21 study is to systematically investigate the role of multi-level factors on participation of CRC survivors in guideline-based post-treatment surveillance care. We will investigate the role of personal factors (e.g., health status, knowledge, attitudes and demographics), provider (e.g. physician-patient and specialist-primary care communication), and practice level factors (e.g., health care use, insurance) on survivor care experiences and outcomes. In Phase 1, we will conduct and analyze focus groups (FGs) of AA (n=20) and EA survivors (n=20) 1.5 years post-treatment to assess their surveillance care experiences. Two additional FGs (1 with AAs and 1 with EAs, each n=10) will be conducted with survivors who are 2-3 months post- treatment to explore their expectations about, and experiences with, follow-up care. We will also conduct and analyze data from interviews with primary care and specialist MDs (n=20) to assess practices related to surveillance and to pretest modifications to a national physician survey. We will develop a survivor survey and an MD survey to systematically examine barriers and facilitators of surveillance care. In Phase 2, we will use cognitive interviewing techniques with CRC survivors (n=16) to pretest the surveys. We will then evaluate the psychometric properties of the survivor survey (n=150 statewide survivors) and gain estimates of outcome measures to guide a subsequent R01. We will triangulate and synthesize findings to develop multi-level interventions to improve the transition from cancer treatment to follow-up by delineating specific strategies most likely to influence patient, provider and practice level enablers. We will use intervention mapping methods to develop theory-driven objectives and intervention strategies and messages. The proposed work is of vital importance and is timely with scientific and clinical relevance. Additionally, the study will be conducted at two National Cancer Institute-funded health care sites in SC, which have diverse geographic areas, a large proportion of AA adults and relevant health disparities. The study results will lead to a future R01 trial in which the theoretically guided recommendations for targeted intervention strategies and messages developed in this study will be tested to improve adherence. PUBLIC HEALTH RELEVANCE: CRC survivors face high rates of recurrence, so adherence to post-treatment surveillance care is critical to reducing their morbidity and mortality. This study will investigate multi-level factors (personal, provider, organization/practice level) which are related to guideline recommended surveillance care. Findings will be used to design culturally appropriate interventions to improve adherence.